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NPI Code Detail

MEDICARE: MARISSA LYNNAE MAXHAM PTA

MEDICARE: MARISSA LYNNAE MAXHAM PTA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12081H0002XHospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician160.008997IL
22081P2900XPain Medicine (Physical Medicine & Rehabilitation) Physician160008997IL

General Provider Information

NPI Number : 1205405859
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARISSA LYNNAE MAXHAM PTA
Provider Business Mailing Address
First Line : 702 SHADWELL AVE
Second Line :
City : FLORA
State : IL
Zip : 62839-2309
Country : US
Telephone Number : 618-842-4138
Fax Number :
Provider Business Practice Location Address
First Line : 701 SHADWELL AVE
Second Line :
City : FLORA
State : IL
Zip : 62839-2310
Country : US
Telephone Number : 618-662-8361
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/18/2021
Last Update Date : 06/18/2021

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